30 Day Change Form

1935 North Meridian Street
Indianapolis, IN 46202
Phone: 317.261.7200 | Fax 317.261.7265
Email Address: Web-HCVClients@indyhousing.org

Fields marked with * must be filled out, or form will not submit.

Requesting a Change in Household Income and/or Family Composition

Failure to complete this form and submit all required mandatory verification and/or documentation will result in your interim request being delayed and/or canceled.

IHA requires program applicants/participants to report interim changes within thirty (30) calendar days of when the change occurs in writing. Failure to comply with this requirement may result in termination of housing assistance and/or retroactive rent charges. Also, IHA is unable to accept any change in household income requests, if the income change will not last at least thirty (30) days.

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(for example \"hours at work increased\", \"had a baby\", \"child moved out\" etc.","name":"Explain-the-Change","subtype":"textarea","className":"d-block"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"paragraph","subtype":"p","label":"3. Specific Mandatory Verifications Required: All documents provided must be dated within the last 60 days.","className":"d-block"},{"type":"radio-group","label":"Mandatory Verification, if reporting a change in earned (employment) income:","name":"Mandatory-Verification-if-reporting-a-change-in-earned-employment-income","className":"d-block","values":[{"label":"Increased or decreased household earned income (hours, wage or employer), attach the following: 4 consecutive paycheck stubs (only if new employer, increased or decreased employment income), or","value":"Increased or decreased household earned income (hours, wage or employer), attach the following: 4 consecutive paycheck stubs (only if new employer, increased or decreased employment income), or"},{"label":"Employment Termination/Separation (*Pay check stubs are not an acceptable form of verification*) Please upload a letter on employers letter head indicating date of termination/separation, and anticipated return date, if applicable.","value":"Employment Termination/Separation (*Pay check stubs are not an acceptable form of verification*) Please upload a letter on employers letter head indicating date of termination/separation, and anticipated return date, if applicable."}]},{"type":"file","label":"Please Upload Documents for Change in Income. You may upload up to 20 files (35 Mb max). Files can be PDF, JPG, JPEG format. To upload multiple files, please hold control while clicking on multiple files before clicking \"Open\".","name":"Please-Upload-Documents-for-Change-in-Income","subtype":"file","multiple":true,"className":"d-block"},{"type":"text","label":"Name of Employer","name":"Name-of-Employer","className":"col-lg-4","subtype":"text"},{"type":"text","subtype":"tel","label":"Employer Phone Number","name":"Employer-Phone-Number","className":"col-lg-4"},{"type":"text","subtype":"tel","label":"Employer Fax Number ","name":"Employer-Fax-Number","className":"col-lg-4"},{"type":"text","label":"Employer Street Address","name":"Employer-Street-Address","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","label":"Employer City","name":"Employer-City","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"select","label":"Employer State","name":"Employer-State","className":"col-md-6 col-lg-3","values":[{"label":"Alabama","value":"AL"},{"label":"Alaska","value":"AK"},{"label":"Arizona","value":"AZ"},{"label":"Arkansas","value":"AR"},{"label":"California","value":"CA"},{"label":"Colorado","value":"CO"},{"label":"Connecticut","value":"CT"},{"label":"Delaware","value":"DE"},{"label":"District of Columbia","value":"DC"},{"label":"Florida","value":"FL"},{"label":"Georgia","value":"GA"},{"label":"Hawaii","value":"HI"},{"label":"Idaho","value":"ID"},{"label":"Illinois","value":"IL"},{"label":"Indiana","value":"IN","selected":true},{"label":"Iowa","value":"IA"},{"label":"Kansas","value":"KS"},{"label":"Kentucky","value":"KY"},{"label":"Louisiana","value":"LA"},{"label":"Maine","value":"ME"},{"label":"Maryland","value":"MD"},{"label":"Massachusetts","value":"MA"},{"label":"Michigan","value":"MI"},{"label":"Minnesota","value":"MN"},{"label":"Mississippi","value":"MS"},{"label":"Missouri","value":"MO"},{"label":"Montana","value":"MT"},{"label":"Nebraska","value":"NE"},{"label":"Nevada","value":"NV"},{"label":"New Hampshire","value":"NH"},{"label":"New Jersey","value":"NJ"},{"label":"New Mexico","value":"NM"},{"label":"New York","value":"NY"},{"label":"North Carolina","value":"NC"},{"label":"North Dakota","value":"ND"},{"label":"Ohio","value":"OH"},{"label":"Oklahoma","value":"OK"},{"label":"Oregon","value":"OR"},{"label":"Pennsylvania","value":"PA"},{"label":"Rhode Island","value":"RI"},{"label":"South Carolina","value":"SC"},{"label":"South Dakota","value":"SD"},{"label":"Tennessee","value":"TN"},{"label":"Texas","value":"TX"},{"label":"Utah","value":"UT"},{"label":"Vermont","value":"VT"},{"label":"Virginia","value":"VA"},{"label":"Washington","value":"WA"},{"label":"West Virginia","value":"WV"},{"label":"Wisconsin","value":"WI"},{"label":"Wyoming","value":"WY"}]},{"type":"text","label":"Employer Zip Code","name":"Employer-Zip-Code","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h4","label":"Mandatory Verification, If Reporting a Change in Unearned Income:","className":"d-block"},{"type":"checkbox-group","label":"Most Recent Award Letter From:","name":"Most-Recent-Award-Letter-From","className":"d-block","values":[{"label":" TANF, Social Security Administration (SS/SSI benefits), State Unemployment Compensation Benefits, Worker's Compensation Benefit Statement, Current Pension Benefit Statement (i.e. Retirement, Veteran's Administration, etc.), Child Support court order or 12- month child support payment printout, General contributions statement (must be signed by contributor)","value":" TANF, Social Security Administration (SS/SSI benefits), State Unemployment Compensation Benefits, Worker's Compensation Benefit Statement, Current Pension Benefit Statement (i.e. Retirement, Veteran's Administration, etc.), Child Support court order or 12- month child support payment printout, General contributions statement (must be signed by contributor)"}]},{"type":"file","label":"Upload Your Most Recent Award Letter. <br>You may upload up to 20 files (35 Mb max). Files can be PDF, JPG, JPEG format. To upload multiple files, please hold control while clicking on multiple files before clicking \"Open\".","name":"most-recent-award-letter","subtype":"file","multiple":true,"className":"d-block"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h4","label":"Mandatory Verification, If Reporting a Change in Expenses","className":"d-block"},{"type":"checkbox-group","label":"Verification of Expenses:","name":"Verification-of-Expenses","className":"d-block","values":[{"label":"Letter from child care provider which include the following: provider name, address, telephone number, weekly rate for care AND Verification of aniticapted ongoing medical expenses (does not include previous bills)","value":"Letter from child care provider which include the following: provider name, address, telephone number, weekly rate for care AND Verification of aniticapted ongoing medical expenses (does not include previous bills)"}]},{"type":"file","label":"Upload a Verification of Expenses. <br>You may upload up to 20 files (35 Mb max). Files can be PDF, JPG, JPEG format. To upload multiple files, please hold control while clicking on multiple files before clicking \"Open\".","name":"verification-of-expenses","subtype":"file","multiple":true,"className":"d-block"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"paragraph","subtype":"p","label":"<b>Household Composition </b>(Please check appropriate box and explain your change below). <b><i>IHA will only add a family member as a result of birth, adoption, or court-awarded custody.</i></b>","className":"d-block"},{"type":"text","label":"Family Member 1: First Name","name":"Family-Member-1-First-Name","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Family Member 1: Last Name","name":"Family-Member-1-Last-Name","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Family Member 1: Date of Birth","name":"Family-Member-1-Date-of-Birth","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Family Member 1: Social Security Number","name":"Family-Member-1-Social-Security-Number","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Family Member 1: Race","name":"Family-Member-1-Race","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Family Member 1: Move in Date","name":"Family-Member-1-Move-in-Date","className":"col-lg-4","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"text","label":"Family Member 2: First Name","name":"Family-Member-2-First-Name","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Family Member 2: Last Name","name":"Family-Member-2-Last-Name","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Family Member 2: Date of Birth","name":"Family-Member-2-Date-of-Birth","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Family Member 2: Social Security Number","name":"Family-Member-2-Social-Security-Number","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Family Member 2: Race","name":"Family-Member-2-Race","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Family Member 2: Move in Date","name":"Family-Member-2-Move-in-Date","className":"col-lg-4","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"checkbox-group","label":"<b>Increase in Family Size (Adding a family member):</b>","name":"Increase-in-family-size","className":"d-block","values":[{"label":"Increase in Family Size","value":"Increase in Family Size"}]},{"type":"paragraph","subtype":"p","label":"<b>Children under 18 must provide the following: </b><br>Adoption papers, and/or court awarded custody papers, <br>Provide Social Security Card,<br>Declaration 214 Form (HUD Form)","className":"d-block"},{"type":"text","label":"Explain the Change in Family Size","name":"Explain-the-Change-in-Family-Size","className":"d-block","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"checkbox-group","label":"<b>Decrease in Family Size (removing a family member)</b>","name":"Decrease-in-family-size","className":"d-block","values":[{"label":"Decrease in Family Size","value":"Decrease in Family Size"}]},{"type":"paragraph","subtype":"p","label":"<b>Please answer questions below. IHA needs verification that the individual is residing elsewhere.</b>","className":"d-block"},{"type":"text","label":"Who moved out of the unit?","name":"Who-moved-out-of-the-unit","className":"col-md-6","subtype":"text"},{"type":"text","label":"When did they move out of the unit?","name":"When-did-they-move-out-of-the-unit","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"paragraph","subtype":"p","label":"Where did they go? <i>Provide New Address</i>","className":"d-block"},{"type":"text","label":"New Street Address","name":"New-Street-Address","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","label":"New City","name":"New-City","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"select","label":"New State","name":"State","className":"col-md-6 col-lg-3","values":[{"label":"Alabama","value":"AL"},{"label":"Alaska","value":"AK"},{"label":"Arizona","value":"AZ"},{"label":"Arkansas","value":"AR"},{"label":"California","value":"CA"},{"label":"Colorado","value":"CO"},{"label":"Connecticut","value":"CT"},{"label":"Delaware","value":"DE"},{"label":"District of Columbia","value":"DC"},{"label":"Florida","value":"FL"},{"label":"Georgia","value":"GA"},{"label":"Hawaii","value":"HI"},{"label":"Idaho","value":"ID"},{"label":"Illinois","value":"IL"},{"label":"Indiana","value":"IN"},{"label":"Iowa","value":"IA"},{"label":"Kansas","value":"KS"},{"label":"Kentucky","value":"KY"},{"label":"Louisiana","value":"LA"},{"label":"Maine","value":"ME"},{"label":"Maryland","value":"MD"},{"label":"Massachusetts","value":"MA"},{"label":"Michigan","value":"MI"},{"label":"Minnesota","value":"MN"},{"label":"Mississippi","value":"MS"},{"label":"Missouri","value":"MO"},{"label":"Montana","value":"MT"},{"label":"Nebraska","value":"NE"},{"label":"Nevada","value":"NV"},{"label":"New Hampshire","value":"NH"},{"label":"New Jersey","value":"NJ"},{"label":"New Mexico","value":"NM"},{"label":"New York","value":"NY"},{"label":"North Carolina","value":"NC"},{"label":"North Dakota","value":"ND"},{"label":"Ohio","value":"OH"},{"label":"Oklahoma","value":"OK"},{"label":"Oregon","value":"OR"},{"label":"Pennsylvania","value":"PA"},{"label":"Rhode Island","value":"RI"},{"label":"South Carolina","value":"SC"},{"label":"South Dakota","value":"SD"},{"label":"Tennessee","value":"TN"},{"label":"Texas","value":"TX"},{"label":"Utah","value":"UT"},{"label":"Vermont","value":"VT"},{"label":"Virginia","value":"VA"},{"label":"Washington","value":"WA"},{"label":"West Virginia","value":"WV"},{"label":"Wisconsin","value":"WI"},{"label":"Wyoming","value":"WY"}]},{"type":"text","label":"New Zip Code","name":"New-Zip-Code","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"paragraph","subtype":"p","label":"Must attach documentation showing the person lives elsewhere: signed lease, utility/other bills, mail, post office completed change of address, school enrollment papers, pay stubs, court papers or documentation from other sources dated within last 60 days. <b>Once an adult family member has been removed they will no longer be allowed to be added back to the household or assistance.</b>","className":"d-block"},{"type":"file","label":"Attach documentation here. You may upload up to 20 files (35 Mb max). Files can be PDF, JPG, JPEG format. To upload multiple files, please hold control while clicking on multiple files before clicking \"Open\".","name":"Attach-documentation-here","subtype":"file","multiple":true,"className":"d-block"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"paragraph","subtype":"p","label":"<b>Certification of Participation and Release of Information</b>","className":"d-block"},{"type":"checkbox-group","required":true,"label":"I certify by my signature that all the information I have reported herein is true and completed. I have read and understand this interim change and my responsibility.<br>1. ALL changes in income for all household members must be reported in writing within thirty (30) days of the change.<br>2. ALL changes NOT reported within the thirty (30) day reporting period WILL NOT receive a 30 day notice in the event of an increase.<br>3. The Voucher Holder is responsible for the current rent until all changes are processed. Voucher Holder will be notified by mail when change is completed.","name":"I-certify-by-my-signature-that-all-the-information-I-have-reported-herein-is-true-and-completed","className":"d-block","values":[{"label":"I certify","value":"I certify"}]},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"text","required":true,"label":"Head of Household First Name","name":"Head-of-Household-First-Name","className":"col-lg-4","subtype":"text"},{"type":"text","required":true,"label":"Head of Household Last Name","name":"Head-of-Household-Last-Name","className":"col-lg-4","subtype":"text"},{"type":"text","subtype":"tel","required":true,"label":"Current Phone Number ","name":"Current-Phone-Number","className":"col-lg-4"},{"type":"text","required":true,"label":"First Name of Household Member being involved/affected:","name":"First-Name-of-Household-Member-being-involvedaffected","className":"col-md-6","subtype":"text"},{"type":"text","required":true,"label":"Last Name of Household Member being involved/affected:","name":"Last-Name-of-Household-Member-being-involvedaffected","className":"col-md-6","subtype":"text"},{"type":"text","required":true,"label":"Unit Street Address","name":"Unit-Street-Address","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","required":true,"label":"Unit City","name":"Unit-City","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"select","required":true,"label":"Unit State","name":"Unit-State","className":"col-md-6 col-lg-3","values":[{"label":"Alabama","value":"AL"},{"label":"Alaska","value":"AK"},{"label":"Arizona","value":"AZ"},{"label":"Arkansas","value":"AR"},{"label":"California","value":"CA"},{"label":"Colorado","value":"CO"},{"label":"Connecticut","value":"CT"},{"label":"Delaware","value":"DE"},{"label":"District of Columbia","value":"DC"},{"label":"Florida","value":"FL"},{"label":"Georgia","value":"GA"},{"label":"Hawaii","value":"HI"},{"label":"Idaho","value":"ID"},{"label":"Illinois","value":"IL"},{"label":"Indiana","value":"IN","selected":true},{"label":"Iowa","value":"IA"},{"label":"Kansas","value":"KS"},{"label":"Kentucky","value":"KY"},{"label":"Louisiana","value":"LA"},{"label":"Maine","value":"ME"},{"label":"Maryland","value":"MD"},{"label":"Massachusetts","value":"MA"},{"label":"Michigan","value":"MI"},{"label":"Minnesota","value":"MN"},{"label":"Mississippi","value":"MS"},{"label":"Missouri","value":"MO"},{"label":"Montana","value":"MT"},{"label":"Nebraska","value":"NE"},{"label":"Nevada","value":"NV"},{"label":"New Hampshire","value":"NH"},{"label":"New Jersey","value":"NJ"},{"label":"New Mexico","value":"NM"},{"label":"New York","value":"NY"},{"label":"North Carolina","value":"NC"},{"label":"North Dakota","value":"ND"},{"label":"Ohio","value":"OH"},{"label":"Oklahoma","value":"OK"},{"label":"Oregon","value":"OR"},{"label":"Pennsylvania","value":"PA"},{"label":"Rhode Island","value":"RI"},{"label":"South Carolina","value":"SC"},{"label":"South Dakota","value":"SD"},{"label":"Tennessee","value":"TN"},{"label":"Texas","value":"TX"},{"label":"Utah","value":"UT"},{"label":"Vermont","value":"VT"},{"label":"Virginia","value":"VA"},{"label":"Washington","value":"WA"},{"label":"West Virginia","value":"WV"},{"label":"Wisconsin","value":"WI"},{"label":"Wyoming","value":"WY"}]},{"type":"text","required":true,"label":"Unit Zip Code","name":"Unit-Zip-Code","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"text","required":true,"label":"I, _______ do authorize any agencies, offices, groups, school, organization or business firm to release to the Indianapolis Housing Agency any information or materials which are deemed necessary to complete my application for participation and/or to maintain continued eligibility in any housing program. I understand and agree that this authorization of the information obtained with its use may be given to and used by the Department of Housing and Urban Development (HUD) in administering and enforcing program rules and policies.","name":"I-do-authorize","className":"d-block","subtype":"text"},{"type":"checkbox-group","required":true,"label":"I understand and agree that HUD or the Indianapolis Housing Agency may conduct computer-matching programs to verify the information supplied for my application or certifications. If a computer match is done, I understand that I have a right to notification of any adverse information found and a chance to disprove that information. HUD may, in the course of its duties, exchange such automated information with other Federal, State, or local agencies, including but not limited to: State Employment Security Agencies' Department of Defense, Office of Personnel Management; the U.S. Postal Department; Social Security Agency, and State welfare and food stamp agencies.","name":"I-understand-and-agree","className":"d-block","values":[{"label":"I understand","value":"I understand"}]},{"type":"checkbox-group","required":true,"label":"This Authorization shall continue from the date of signature and such time the Indianapolis Housing Agency is notified inwriting that the authorization is cancelled. I agree that a photocopy of this authorization may be used for the purpose stated above.","name":"I-agree-that-a-photocopy-of-this-authorization-may-be-used-for-the-purpose-stated-above","className":"d-block","values":[{"label":"I agree","value":"I agree"}]},{"type":"text","required":true,"label":"Signature of Head of Household","placeholder":"By typing your name, you are signing this document.","name":"Signature-of-Head-of-Household","className":"col-lg-4","subtype":"text"},{"type":"date","required":true,"label":"Date of Head of Household Signature","name":"Date-of-Head-of-Household-Signature","className":"col-lg-4"},{"type":"text","required":true,"label":"Head of Household Social Security Number","placeholder":"xxx-xx-xxxx","name":"Head-of-Household-Social-Security-Number","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Signature of Other Adult Household Member","placeholder":"By typing your name, you are signing this document.","name":"Signature-of-Other-Adult-Household-Member","className":"col-lg-4","subtype":"text"},{"type":"date","label":"Date of Other Adult Household Member Signature","name":"Date-of-Other-Adult-Household-Member-Signature","className":"col-lg-4"},{"type":"text","label":"Other Adult Household member Social Security Number","placeholder":"xxx-xx-xxxx","name":"Other-Adult-Household-member-Social-Security-Number","className":"col-lg-4","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"paragraph","subtype":"p","label":"Reasonable Accommodation: If you, or any household member, have a disability that could prevent your full access to or utilization of IHA's Housing Choice Voucher Program and its related services, you have the right to request a reasonable accommodation. A reasonable accommodation may include a modification of a rule, policy, procedure or service that will assist an otherwise eligible disabled applicant or resident to make effect use of its programs. If you believe you require a Reasonable Accommodation, please contact your Housing Specialist or complete the Reasonable Accommodation Request form.","className":"d-block"}]

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